Medication Order Form
This form is to be completed by
a physician and parent before any prescription medication can be
administered in school.
Name of
Student______________________ DOB ____________ Grade_________
Medication__________________________
Dosage__________ Route____________
Frequency________________ Time(s)
to be given at school_____________________
(Please Note: Whenever possible, medication should be
scheduled at times other than school hours)
Possible Side
Effects______________________________________________________
Specific Directions or information
for administration: ___________________________
Date of Order___________________ Discontinuation Date__________________
Diagnosis*_____________________ Drug/Food
Allergies________________________
Name of Licensed Prescriber____________________________ Title_______________
Signature of Licensed Prescriber_____________________________ Date____________
Address______________________________________
Phone_______________
* if not
in violation of confidentiality
Name of Parent/Guardian______________________ Relationship
to student__________
List of Additional Medication taken at
home____________________________________
____ Yes _____
No I give permission for my
son/daughter to self-administer medication, if the school nurse determines it
is safe and appropriate.
I consent to have the School Nurse or school personnel
designated by the School Nurse to administer the above medication to my
child. I give permission to the School
Nurse to share information relevant to the prescribed medication administration
as he/she determines appropriate for my son’s/daughter’s
health and safety. I understand I may
retrieve the medication from the school at any time; however, the medication
will be destroyed if it is not picked up within one week following termination
of the order or one week beyond the close of school.
Signature of
Parent/Guardian_______________________________ Date____________
Telephone (home) _______________
(work) ______________ Cell/Pager____________